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“We have to ask ourselves whether medicine is to remain a humanitarian and respected profession or a new but depersonalized science in the service of prolonging life rather than diminishing human suffering.”

Elisabeth Kübler-Ross, MD (July 8, 1926–August 4, 2004)

“You matter to the last moment of your life, and we will do all we can, not only to help you die peacefully, but also to live until you die.”

Dame Cicely Saunders (June 22, 1918–July 14, 2005)

This update of the 2005 four-part JAOA supplement series devoted to pain management and available only online concludes with this edition focusing on management of cancer pain. The authors represent various professionals who are members of interdisciplinary teams treating patients with cancer. They provide perspectives and opinions on treatment of these patients in whom pain is inevitable, but suffering should not be, especially when managed by holistic care This edition also includes two new and important articles from a hospice bereavement coorinator and counselor and a hospice director of pastoral care who have much experience in dealing with helping dying patients, their families, and their physicians through the grief and bereavement process. Their perspective is unique and different than that of the traditional health professional.

Authors have added case presentations to each of the articles to provide key teaching points to help primary care physicians treat patients for cancer-associated pain. The CME Quiz includes new questions to reinforce the topics that the authors consider important to enhance readers' understanding.

The mortality rate attributed to cancer remains second only to that of cardiovascular disease. It has been estimated that more than 1.3 million new cases of cancer were diagnosed in the United States in 2004, and, despite advances in treatment, at least 560,000 patients with cancer died during that same year.1 Mortality rates have steadily decreased in men with lung, colon, and prostate cancer, and in women with breast and colon cancer. Advancements in treatment have led to a steadily increasing number of cancer survivors. Yet, pain remains the primary concern.

Most patients with cancer fear pain as their worst symptom. Indications are that 30% of those with newly diagnosed cancer and 80% with previously diagnosed cancer have complaints of pain.2

In 1986, the World Health Organization (WHO) developed guidelines with a stepped approach for providing analgesia in patients with cancer.3,4 These guidelines were designed to simplify and allow the management of pain by healthcare providers with limited knowledge of narcotic analgesics. The WHO three-step process starts with basic analgesics, including acetaminophen, acetylsalicylic acid (ASA), and other nonsteroidal anti-inflammatory drugs. If pain control is inadequate, the second step recommends combination therapy of opioids with ASA or acetaminophen. If these first two steps do not achieve pain control. a third level consists of adding more potent opioids, including those available in sustained-released formulations. Use of these WHO guidelines could allow 90% of patients to achieve significant analgesia. Subsequent modifications with inclusion of palliative methods should be able to completely control cancer pain.

Despite these guidelines, inadequate provision of analgesia in patients with cancer remains a serious problem. Myths and attitudes concerning use of opioids by healthcare providers, patients, and their families are major obstacles to pain relief. Deficits in knowledge and understanding of addiction, diversion, tolerance, and physical dependence are only part of this problem. Governmental involvement at both state and federal levels may limit prescribers from dispensing proper doses to alleviate symptoms because of fear of sanctions or legal actions.

This supplement offers various approaches to patients with cancer, yet the underlying goal is pain relief. The spiritual aspect and its importance to patient understanding of death and suffering is not a traditional approach dealt with in medical school lectures. Our recognition of this aspect of patient care can promote acceptance of certain treatment modalities or medications. Barbara Schaefer Bitros, RN, a hospice nurse, is a patient advocate. As physicians, we can become immersed in saving lives at the cost of ignoring the requests of the patient or the family or both concerning sanctity of life and death issues. The article by Nurse Bitros focuses on an individual's humanity in contradistinction to a clinical subject with a diagnosis.

Palliative care, a newer concept, is the subject of the presentation by Mehul Desai, MD, Ann Kim, MD; Patrick Fall, DO; and Dajie Wang, MD. They compare hospice and palliative therapies and discuss other interventional procedures used to reduce pain and provide comfort.

Lynette A. Menefee Pujol, PhD, and Daniel A. Monti, MD, look at alternative and nonpharmacologic treatment of patients with cancer pain. Linqiu Zhou, MD, and I focus on pharmacologic treatment of patients with cancer pain; our discussion of past as well as current management plans serves as an introduction to the basics of the WHO guidelines.

Finally, Reverend Bruce and Reverend Wess provide new articles dealing with grief and the process of bereavement, an approach helpful for healthcare professionals who deal with complex cultural and religious aspects of the dying patient. Their perspective is important and a positive feature that complements articles written primarily by healthcare professionals. Their insight inspired the tag line and concept for the art that appear on this edition's cover. The fragile beauty of the butterfly touches mind and spirit without using any overtly religious symbols.

It is our hope that this supplement, which includes both traditional and nontraditional topics, changes the readers' approaches to pain management such that they provide not only pharmacologic but also holistic methods to their terminally ill patients with cancer and attendant pain.

In the words of the Dalai Lama, “Pain is inevitable. Suffering is optional.” It is our work to make suffering optional in our patients with cancer.